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Wiki Ros in hpi???

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jifnif

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i have a report that the dr is stating in the ROS that "10 system review negative except what is noted in HPI' and the only thing noted in HPI is basically history. Is this allowed to be counted as ROS? I want to say no but would love to have another opinion. Thank you. :)
 
More!?

I am new to this type of coding but it seems the norm for our hospitalists to state in ROS that it is negative except for what is mentioned in HPI. Please, if someone knows if this is allowable let me know. Thanks.
 
The ROS can be taken from the HPI, you just need to be careful that you aren't "double dipping" and using the same info more than once.

I had a co-worker bring me an example of one of her hospitalists notes. There was no ROS done in the HPI but there was a comment "ROS neg except as noted above". We don't give credit for that.

Many times a good HPI will have a few really clear ROS in it so they won't need to have a separate ROS.

Currently, depending on your carrier, the all other systems reviewed and negative is acceptable as a comprehensive ROS. This is of course assuming there were some ROS listed and it is actually being done.

It would be nice if you could post the HPI in question so we could go thru it with you.

Laura, CPC, CEMC
 
tHANKS! I will try to retype it as acurate as possible, we don't have a copy paste option:

HPI: History from patient, family and medical records. pt is 86 woman w/ history of metastatic colon carcinoma w/ metastasis fo the liver, lung and brain. the pt had completed a course of her brain radiation and following which the pt was admitted to .... after having found calcium levels on routine b/w. the pt was admitted w/ a calcium level of 13.1. the pt was treated w/ aredia for her hypercalcemia and a neurology consult was obtained for new onset of ext weakness. the pt underwent further investigation for her weakness and was found to have a right parietal mass on the brain MRi. the pt was known to have cerebral metastatic disease status post radiation therapy as mentioned above. the pt is also known to have seizure disorder 2ndary to her metastatic disease. the pt metabolic parameters including her calcium had improved and was 9.5 today. she is being admitted to acute rehab unit.

and in the ROS area: Ten point ROS is negative except for symptoms mentioned in HPI.

Thanks for all help. :)
 
What type of visit?

I'm thinking this may be a subsequent hospital visit? An inpatient consult? A discharge? An admission to rehab?

Seems like patient was already admitted and neuro consult previously obtained ... or is this the neuro consult?

In any case ... There are 14 systems in the ROS. Saying "10 point ROS completed" does NOT get ANY points in my book because I don't know which 10 of the 14 were reviewed.

It does seem that you will have more than enough in the HPI to have some ROS ... but I can't figure out what the chief complaint is for this visit, so I don't know which information to count for HPI vs ROS.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Thanks for your help. This is a hospitalist. All of our hospitalists use this terminology on a report regardless if it is a consult or a subsequent visit. Just wondered if you could pull the info from their. :) So are you saying that it should be more clear? B/C to me it just seems like a review of an already done review.
 
Review of Systems from file

You can always take the review of systems and the past medical/family/social history from the patient chart. BUT you do need to reference where you got the information, AND the fact that you reviewed it.

That being said ... for a subsequent hospital visit you only need two of the three elements. Your exam and MDM may be enough to give you your level of care without counting history at all.

Again ... I need to know the chief complaint to fully answer your question. But for illustration purposes, I will assume that the patient is hospitalized for elevated calcium level, so that's my chief complaint.

So for HPI you have context (found on b/w), severity (level was 13.1), modifying factor (treated with aredia) and associated signs (ext weakness).
You can then count for ROS: GI (colon cancer), Resp (lung metastases), Neuro (seizure disorder) (2-9 ROS)

For Past Med Hx you have a course of brain radiation. (For a subsequent hospital visit you only need an "interval pertinent" PMFSH)

So you have a Detailed History ... if you have a Detailed Exam OR High Complex MDM you have a 99233.

Hope that helps explain the process.

F Tessa Bartels, CPC, CEMC
 
Thanks. It does help. It seems though that as a coder you have to be able to read cryptic messages! I feel like our hospitalist's notes are scrambled. How does someone get into the habit of finding all the little things that help support the code? Did CEMC help you better define the fine lines in E/M? I am struggling to make codes out of mish mosh.
 
Other way around

Actually it was my experience that helped me obtain my CEMC.


But if you accomplish nothing else, get your hospitalists to routinely use this phrasing for their subsequent visit notes ... "14-point review of systems was reviewed by me and is in the Patient H&P." (Of course you'll have to be sure the H&P actually HAS a complete ROS ...)

F Tessa Bartels, CPC, CEMC
 
Ros

We have come accross this as well and are going to visit it in policy as a possible cloning issue.

See the following taken from AHIMA:

Does every patient read almost the same when it comes to the:
  1. Review of systems,
  2. Past personal, family, and social histories, and
  3. Examination?

    If so, why and should they? This is a policy issue that must be addressed. There might be certain specialties where that is appropriate, but make sure it holds up to scrutiny and the documentation is not there merely for coding purposes. What is the clinical relevance?
Click to expand...
Source:
Garrison, Susan E.. "Expert E/M Chart Auditing." 2008 AHIMA Convention Proceedings, October 2008.
 
Ros

I like this thread. I work for hospitalist group and I am struggling with similar situation. Beside ROS and double dipping HPI/ROS. I am also confused about DATA Review. Physician using hospitalist notes with printed labs - I don't know if I could give credit unless they say lab reviewed.

Marinating compliance is one of my objective for my group and to teach physician documentation according to cms guidelines.
 
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